Table 1.

Design features of the clinical associate programme that contributed to initial successes

Design feature	Potential value*
Linkage to training and regulation of doctors
Training of clinical associates is located within medical schools as a 3-year degree course Regulation of the cadre is through the medical and dental board	Confers status on the new cadre Fosters synergy between clinical associates and doctors who have to work closely together Training is quicker and less costly than for a doctor, and there will not be a brain drain overseas as the degree is not recognised internationally Enables post-graduate training which supports career progression
National curriculum and exam
A national curriculum framework guides the courses at different universities Students face both a local and national final exam	Ensures comparable training and maintains standards Allows local flexibility and innovation
Clearly defined position within the district hospital health care team
The clinical associate is conceptualised as part of a collaborative district-level clinical team that includes the doctor working with a primary health care nurse at the clinic and health centre level, and the doctor working with the clinical associate at the district hospital level The scope of practice of the clinical associate is tailored to the specific context and needs of the district hospital There is an emphasis on generalist skills and flexibility in response to the particular situation of the individual hospital and health worker	In tandem with policies to improve district management capacity, supports the development of a particularly weak level of the district health system (i.e. the district hospital) and relieves the workloads of nurses and doctors Responds to the patient profile at district hospitals (district hospitals do not have enough patients with complex conditions that warrant full-time specialist clinical associates, such as an anaesthetic assistant) Clarifies differences in scopes of practices and reporting lines and avoids overlap of roles with primary health care nurses Diffuses concerns of other health professionals Encourages a sense of belonging to a team Creates a ‘pluri-potential’ person who is not locked into specific tasks and is able to adapt to different tasks during their working day and longer-term career
Rural recruitment and training
Students are recruited from rural and other disadvantaged areasThe bulk of training is in rural facilities	Creates a new route of entry into the medical field, especially for students from marginalised communities Produces health workers who can communicate with patients in their home language Enhances retention in rural areas
Supervision by doctors
Adequate supervision and support is ensured through making the presence of a doctor integral to the functioning of a clinical associate	Strengthens quality of care Alleviates concerns about the ability of clinical associates to deliver quality care
Service-based learning
Service-based learning Creation of District Training Complexes	Provides plenty of opportunities for practical learning Allows students to become familiar with local circumstances, the district hospital setting and community in which they will one day work Students demonstrate their usefulness to other staff by immediately relieving their workload Helps to realise the goal of decentralised, multi-disciplinary training that makes health workers better equipped for, and more responsive to, community needs Allows the development of teaching approaches that can be applied to other categories of health professional Provides additional motivation and support for staff, improving recruitment and retention

^*This is the value identified by key informants. Whether the potential has been fully realised needs to be determined by a more comprehensive evaluation.